YAYASAN RUSTIDA

AKADEMI KESEHATAN RUSTIDA Program

Studi DIII Keperawatan Alamat : Jalan RSU.
Bhakti Husada Telp. (0333)821495, Fax:
(0333)821193 KRIKILAN – GLENMORE –
BANYUWANGI
FORMAT PENGKAJIAN ASUHAN KEPERAWATAN
GAWAT DARURAT (GADAR)

Nama Mahasiswa : …………….....................

Semester/Tingkat : 5/3
NIM : …………………………
Tempat Praktek : RSD dr. Soebandi, Jember

Ruangan : ICCU
No. Reg : 00000282118
Tgl Pengkajian : 6 Januari 2020
Jam : 10.00 WIB

DATA KLIEN

A. DATA UMUM
1. Nama inisial klien Ny. R
2. Umur 46 th
3. Alamat Kauman, Tempurejo
4. Agama Islam
5. Tanggal masuk RS/RB 6 Januari 2020
6. Nomor Rekam Medis 00000282118

B. PENGKAJIAN PRIMER:

1. Airway/jalan nafas (paten/tidak jika tidak, penyebabnya, dan suara nafas)
Jalan nafas paten

2. Breathing
a. Inspeksi (bentuk dada/simetris, pola nafas, frekuensi dan irama, jenis pernafasan, bantuan
nafas, dll)
Bentuk dada normal chest, pola nafas ireguler, frekuensi 22x/menit, menggunakan O2 nasal :
4lpm

b. Palpasi (focal fremitus, dll)

Focal fremitus sama antara dada kanan dan kiri, nyeri pada dada kiri

c. Perkusi (pembesaran paru, dll)

Tidak ada pembesaran pada paru

d. Auskultasi (suara nafas)

Suara nafas vesikular

3. Circulation
a. Vital sign:
1) Tekanan darah : 140/100 mmHg
2) Nadi : 85 x/menit
 3) Suhu : 35,6 oC

b. Capilarry refill :>2 detik

c. Sianosis/pucat : Pucat
d. Akral : Dingin
e. Kelembapan : Lembab
f. Turgar :<2 detik
Lain-lain : ………………………………………………………………………

4. Disability
a. GCS/AVPU : 4-5-6, Composmentis
b. Pupil(diameter,isokor/anisokor, respon cahaya) : Pupil isokor, berespon terhadap cahaya
c. Gangguan motorik : Tidak terdapat gangguan motorik pada pasien
d. Gangguan sensorik : Tidak terdapat gangguan sensorik pada pasien

5. Expousere/Environment/Event
a. Adanya trauma pada daerah : tidak terdapat trauma pada daerah tubuh
b. Adanya jejas/luka pada daerah : tidak terdapat luka atau jejas pada daerah tubuh
c. Ukuran luka/jenis luka : tidak ada
d. Kedalaman luka : tidak ada
e. Lain2 (Px. Penunjang/proses kejadian) :

C. SECONDERy SURVEY
6.Five Intervensi/Full Of Vital Sign
a. Five Intervensi
: Terdapat ST elevasi V2 - V5, irama sinus dengan infark anterior
1) EKG
STEMI, irama = sinus, nadi 85
: Terpasang kateter, produksi urine 450 cc/12 jam , warna kuning, bau
2) Cateter
amoniak
3) NGT : Pasien tidak terpasang NGT
4) Sp O2 : 99%
5) Laboratorium :
b. Full Of Vital Sign
1) TD/MAP : 140/100 mmHg , 113,3
2) Nadi : 75 x/menit
3) Suhu : 35,6 oC
4) Rr : 22 x/menit
5) BB : 55 kg
7. Give Comfort/beri kenyamanan
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8.History dan Head to toe

a. History
1) Keluhan utama :
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2) Riwayat pengakit sekarang :
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3) Makan-minum terakhir :
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4) Riwayat medikasi :
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5) Pengalaman pembedahan :
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6) Alergi terhadap obat :
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7) Riwayat penyakit dahulu :
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8) Riwayat penyakit keluarga :
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b. Head to Toe
1) Kepala
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2) Leher
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3) Dada
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4) Abdomen
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5) Ekstremitas
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6) Kulit/integument
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D. TERAPI MEDIS
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Mengetahui, ............................., ……………….20….

Clinical Instructure/CI/Dosen Pembimbing Mahasiswa

(………………………………..) (………………………………..)
 ANALISIS DATA

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................
NO DATA ETIOLOGI MASALAH
 DAFTAR PRIORITAS MASALAH KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Prioritas
Tanggal Muncul DIAGNOSA KEPERAWATAN Tanggal Teratasi
Ke-
1

4
 RENCANA INTERVENSI KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................
Tanggal Pengkajian : ..............................................

Tujuan/ Intervensi/
NO Diagnosa
Nursing Outcome Nursing Intervension Rasional Tindakan
Dx Keperawatan
Criteria (NOC) Criteria (NIC)
 IMPLEMENTASI KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................

Tanggal Pengkajian : ..............................................

Hari, Tanggal Jam Dx Kep Implementasi & Respon

 EVALUASI KEPERAWATAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................

Tanggal Pengkajian : ..............................................

Hari, Tanggal Jam Dx Kep Evaluasi

1 S:

O:

A:

P:

2, dst
 CATATAN PERKEMBANGAN

Nama Pasien/Inisial : ..............................................

Ruang Perawatan : ..............................................

Tanggal Pengkajian : ..............................................

Hari, Tanggal Jam SOAPIE

*Kolom ini digunakan untuk dokumentasi keperawatan hari Ke-2 dst.